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Archive for January, 2013

AIDS Rethinking can hardly ignore questions about homosexuality, because the alternative explanation to a viral cause of AIDS is lifestyle. The AIDS era began among gay men, and correspondingly the “new” disease was initially called Gay Related Immune Deficiency (GRID). Inevitably one asks whether the causative lifestyle had something to do with being gay.

However, the GRID designation and diagnosis rested on an invalid statistical categorization. As John Lauritsen (1) pointed out at the very beginning of the AIDS era, the Centers for Disease Control & Prevention (CDC) had incorrectly identified the first AIDS sufferers as homosexuals (some of whom happened to abuse drugs) instead of as drug abusers, many of whom happened to be homosexual.
That drug abuse can bring on the symptoms of early-1980s AIDS was pointed out by, for example, Gordon Stewart (2). That the early years of gay liberation saw a proportion of gay men overindulging in unhealthy drug-abusing lifestyles has been remarked by, among others, Larry Kramer (3), Michael Callen (4), and Josef Sonnabend (5). Altman (1982, below, p. 80) remarked on the ubiquitous smell of amyl [nitrite, poppers] in gay venues.

I found it easy to accept that exuberant feelings of new-found freedom after lifelong oppression could lead some people to such health-damaging actions, but without any real feel for just what the oppression of homosexuality entailed and entails. I tried to imagine it as essentially analogous to racist or anti-Semitic oppression. But two recently read books make that analogy less appropriate. They have been eye-openers for me on several levels, and I recommend them unreservedly. Both are by Dennis Altman:HOMOSEXUAL: Oppression and Liberation,
Outerbridge & Dienstfrey, 1971 (ISBN 0-87690-039-2); andThe Homosexualization of America, the Americanization of the Homosexual,
St. Martin’s Press, 1982 (ISBN 0-312-38888-8)

One point of high interest is the changes in society — and in the author’s experience — in the decade between the writing of those books. In the 1982 book he doubted that he would live to see change in established churches, so he’s been pleasantly surprised, and no doubt about gay people in military service as well. Altman deplored the German government’s refusal to compensate homosexual men who had been in concentration camps (1982: 112); but that changed after 1985 (6).

Further of general interest is that the second book was written just before AIDS appeared (there is no mention of GRID, AIDS, HIV). Thereby the discussion is not biased by interpretations based on later events.

Perhaps above all, Altman offers a comprehensive, uninhibited discussion of what it has meant to be homosexual, primarily in Western society and with the United States as exemplar; what it meant to live through so-called gay liberation; and what actual and perhaps final liberation might look like.

Though I had not questioned that nominal liberation could lead to irrational exuberance, I did have qualms or reservations about the enormity of the apparently AIDS-inducing behavior. Altman’s insights have helped me to bury those qualms by gaining some feel for the nature and intensity of the oppression that needed to be lifted (and in some ways still needs to be).
It should be recognized, too, that the lifestyle being blamed would not have typically produced seriously debilitating manifest illness rapidly. Contrary to the oft-cited shibboleth that AIDS was first seen in young, previously healthy gay men, in point of fact their average age was mid-to-late thirties and they had histories of health issues (7).

Growing up homosexual in a society that forces homosexuals to closet themselves has a number of damaging consequences:→ One mis-learns that the world is nothing but heterosexual→ Thereby one is hindered from acknowledging or accepting one’s own identity→ Thus society’s influence works like a self-fulfilling prophecy,
tending to mold homosexuals into society’s stereotypes of them,
even into accepting that there’s something wrong with being homosexual (1982: 112-3)→ Homosexuals tend to be conflicted and to feel guilty about their own feelings
which conduces to counterproductive behavior including drug abuse;
some are likely to harbor self-hatred, usually unconscious,
and may over-react to behave in violently homophobic ways

The strength of societal oppression of homosexuals was manifested not only by perpetual brutal police harassment but by such signs as “the Tiffany’s notice — ‘We do not, nor will we in future, carry earrings for men’” (1971: 69).→ Altman does not address the long history of homosexual oppression or acceptance over the millennia in various societies. One source for that is David F. Greenberg, The Construction of Homosexuality (8).→ Western 19th-century designation of homosexuality as illness, maladjustment, perversion reflects and is owing to the development of medicine as both science & ideology.→ Sociological designation of homosexuality as “deviance” was just as stigmatizing as the medical designation. It was pejorative not descriptive; it doesn’t just mean different: nuns aren’t called deviant.

Gay Liberation is widely associated with the Stonewall riot of 1969, but while that was certainly a landmark of progress, genuine liberation remains to be fully attained:→ The considerable gains in tolerance experienced in the last several decades are not the same as the acceptance that true liberation would represent.→ Oppressed minorities do not necessarily appreciate one another’s situation and form common cause. There are black homophobes and gay white racists, for example.→ Just as there is homophobia among heterosexual people, there is heterophobia among homosexual people.

The 1982 title, The Homosexualization of America, refers to the manner in which widespread behavior has come to resemble what was long charged against homosexuals: young, educated, urban Americans frequent singles’ bars, wife-swapping was common at least for a time; casual & recreational sex is increasingly accepted [e.g. nowadays in college students’ “hooking up” and “booty calls” (9)]. The 1971 book cited Tiffany’s ban on selling earrings to men; for years now, quite a number of heterosexual men have been wearing earrings.

Genuine gay liberation has the huge task of creating ab initio guidelines and role models for all aspects of human interaction:→ Homosexual behavior and homosexual identity are two distinct matters. In Moslem countries, for example, homosexual behavior is quite common but homosexual identity is strictly taboo. Homosexual identity is largely a Western urban 19th-century development, and with it the concept of a gay community or sub-culture.→ “Gay community” is not a natural kind, it exists solely because of societal oppression, it’s a pseudo-community.→ Altman and many others believe that polymorphous sexuality, most simply bisexuality, is universal. If so, creation of an homosexual identity requires also acknowledging possibly repressed heterosexual attractions.

Altman’s discussion is meaningful far beyond homosexuality, with insights pertinent to everyone:→ As with all individuals and groups, there is an inevitable tension between expressing uniqueness and acknowledging human universality.→ The liberation of gay men and lesbians is at the same time a liberation of humankind.→ Sex is burdened with excessive and unrealistic expectations of self-fulfillment and personal actualization; and this is exploited commercially via massage parlors, sex shops, porno movie houses. [Add in recent years the salacious TV ads for Viagra, Cialis, and their ilk.]

Chapter 6 (1982) focuses on societal disapproval of sex for its own sake. It is dispassionate and logical and courageous in its discussion of matters rarely spoken of in public: the sexuality of children, including adult/child sex; sadomasochism; interplays of promiscuity and long-term commitments. I doubt that anyone could read this without learning something new or being reminded of something often forgotten, for example, that most child abuse is heterosexual; or that “most studies suggest that men involved in s-and-m are likely to be personally gentle, liberal, and of above-average education”; or that “rape by self-acknowledged homosexuals is very rare — though male rape by those who deny their homosexuality is, of course, widespread” (pp. 196-7).

These are among the chief points that I’ve gained from these books, but such a brief survey cannot do justice to Altman’s comprehensive and nuanced discussions. My hope is to stimulate others to read the books themselves. Little of consequence in them has been superseded after 40 and 30 years respectively, and the last sentence of the 1982 book needs no modification at all:

“In the long run
it would be nice to hope
that we can escape the limitations
on individual identity and diversity
that all categories impose”

In the meantime, Altman’s insights have fleshed out for me how long oppression and the iconic Stonewall presaged AIDS. The sense of freedom brought by Stonewall did not bring with it a viable conception of what normal, i.e. non-oppressed, homosexual life might be like. It is only since the fits and starts of gay marriages that everyone, gay people as much as others, have discovered that there have always been quietly closeted long-term gay partnerships and families. That’s the context in which many gay men mis-interpreted “liberation” to call for excessive indulgence in what had previously been forbidden. Ironically they foreshadowed “HIV’s” latent period: the 10-15 years between Stonewall and AIDS represent the average incubation period for the “side” effects of promiscuous drug abuse and irresponsible sex to result in destruction of the immune system.

Several of my books had gone out of print over the years, including my personal favorites: The Enigma of Loch Ness and To Rise Above Principle: The Memoirs of an Unreconstructed Dean. Now they have been re-issued by Wipf & Stock, with additional material in the Dean’s Memoirs.

The Enigma of Loch Ness is not an argument for or against the reality of Nessies. As the sub-title, Making Sense of a Mystery, suggests, the book addresses such questions as
“Why has science not taken an interest in this claim?”
“What’s different about looking for Nessies and doing science, say, searching for new species?”
In discussing what differentiates science from not-science, I introduce the concept that scientific activity has 3 aspects: facts, methods, and theories. Science progresses normally by not rocking the boat in any of those aspects. Occasional scientific revolutions see dramatic change in one of those aspects. When two are in question, the claim is likely to be ignored by the mainstream for quite a long time (Mendelian genetics, continental drift). Claims that are unorthodox in all 3 aspects tend to be shunned as pseudo-science.

To Rise Above Principle was published under a pen-name because I did not want my semi-imaginative scenarios and semi-invented characters to be identified with my institution or its people. A year later, when that danger no longer seemed pressing, I had the opportunity to reveal my identity at an annual meeting of the Council of Colleges of Arts & Sciences, and this new edition of the book contains the text of what I said on that occasion. Another new appendix has my introduction to a panel discussion of what a dean’s career involves, and a third appendix reproduces my change of mind on the matter of homosexuality, earlier published in a book review and posted on my website.

Both books received high critical praise when they were published. All but one review of the Nessie book noted that it was not an argument for or against and praised my evenhandedness despite my confessed personal view. The demurring review misled by implying that the book was an attempt to argue for the reality of Nessies; it had been written by someone who had earlier asked without success to be invited to give a seminar at my university — an illustration of the pitfalls of “peer” review [Peer review and consensus (Scientific literacy, lesson 2)].

The advent of antiretroviral “cocktails”, combination antiretroviral therapy, HAART, is said to have made HIV/AIDS a manageable chronic disease to the extent that “HIV-positive” individuals can lead essentially normal lives for essentially normal life-spans — at least according to official statements repeated by the media from interviews with gurus and VIPs and from press releases put out by government agencies and by drug companies.

The technical literature, on the other hand, is replete with descriptions of highly unpleasant, health-threatening “side” effects from all antiretroviral drugs and combinations. Note for instance that the Treatment Guidelines have been revised once or twice a year for well over a decade, and revisions are made on-line even more frequently, raising suspicions as to just when the treatment became so successful as to permit normal living and why recommendations have still needed to be revised so often.
Moreover, if treatments are so successful, what need is there for patients to “understand the . . . risksof therapy” [emphasis added] and to consider deferring therapy? (Treatment Guidelines, 27 March 2012 version, introductory pages):
“Patients starting ART should be willing and able to commit to treatment and should understand the benefits and risks of therapy and the importance of adherence . . . . Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy on the basis of clinical and/or psychosocial factors”.

One wonders, too, at such sections in the Guidelines as “What Not to Use: Table 8. Antiretroviral Regimens or Components That Should Not Be Offered At Any Time”.
This includes not only the NRTI monotherapy and Dual-NRTI therapy that was officially lauded from the late 1980s into the mid-1990s before being suddenly superseded. “What Not to Use” also lists a goodly number of combination therapies that were earlier recommended!

There are hints everywhere in these Guidelines that what was once recommended is to be avoided; for example, Table 8 includes such rather inscrutable comments as
“Clinicians caring for patients who are clinically stable on regimens containing TDF + ddI should consider altering the NRTIs to avoid this combination”: Obviously this earlier recommended treatment isn’t all that good. Some earlier combinations are now labeled “When no other ARV options are available and potential benefits outweigh the risks”: What risks? That one might lead a normal life?

“Adherence to treatment” qualifies for quite a bit of discussion in which “adverse drug effects” and “treatment fatigue” are mentioned only toward the end of a list that includes what some people (including me) might regard as nonsense, e.g. “low levels of health literacy . . . or numeracy (ability to understand numerical-related health information)”, which presumably means not believing what they are told when they complain of the debilitating effects of the treatment.

This blog post was stimulated by a recent press release (31 December 2012) from the Food and Drug Administration: “FDA approves first anti-diarrheal drug for HIV/AIDS patients — Fulyzaq is the second botanical drug approved by the agency . . . . [It is to be used] to relieve symptoms of diarrhea in HIV/AIDS patients taking antiretroviral therapy . . . . Diarrhea is experienced by many HIV/AIDS patients and is a commonreason why patients discontinue or switch their antiretroviral therapies. . . . The median number of daily watery bowel movements was 2.5” (emphasis added; hardly the normal life claimed in official propaganda).
A minor point of interest here is that a “botanical drug” is good when recommended by an official agency, but of course not when it comes from anyone who advises an “alternative” or “complementary” medical approach (“More mainstream alternative treatment for ‘HIV/AIDS’”).

The main general point I want to make is that one learns about the real effects of antiretroviral therapy only from reading between the lines of the official statements and looking into the underlying data. In particular,

continuing praise of new improvements in therapymeans inevitably that earlier treatments were less than completely satisfactory,though that is never stated outright.

For example, that AZTdid nothing beneficial and actually killed some proportion of patients has to be inferred from such hints as that it was omitted from estimates of how antiretroviral drugs had decreased mortality “[c]ompared with . . . untreated HIV disease” (“The survival benefits of AIDS treatment in the United States”, Walensky et al., Journal of Infectious Diseases 194 [2006] 11-19); or from noting that when AZT monotherapy was replaced by cocktails, there was an immediate halving in mortality, indicating that AZT had been responsible for about 150,000 deaths (“HAART saves lives — but doesn’t prolong them!?”).

After many years of paying attention to these things, I remain astonished that public pronouncements by official agencies are so stunningly at odds with what is in the technical literature. One simply cannot rely on supposedly authoritative sources. Nor is that only my conclusion:

It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines.I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine
—— Marcia Angell
“Drug companies and doctors: a story of corruption,”New York Review of Books, 56 #1, 15 January 2009.